Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The "soldier’s heart" of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Yet, there are also unique aspects of the combat experience of these veterans that influence their psychiatric presentations in acute settings.

First, far more of the troops (up to 45%) are reserve or National Guard rather than active duty compared with earlier wars.4 Their combat exposure, severity of PTSD, and impairments in interpersonal functioning are more similar to those experienced by career military.5 These individuals are most likely to appear in crises in community emergency departments (EDs); they may present with problems that may be different from veterans of previous wars or from soldiers in active military duty.

Typical presenting symptoms are marital stress from unexpectedly long deployments of 15 months (rather than the standard 12), employment concerns, financial stresses, and overall difficulty in reintegrating into civilian life. The absence of a strong military identity and cohesion, geographical separation from comrades, greater stigma, and misunderstanding from communities without exposure to the military or combat trauma serve as formidable barriers to care for these citizen-soldiers.

Second, multiple deployments have become the expectation. Many soldiers serve 2, 3, or even 4 tours of duty—a phenomenon unparalleled in other conflicts. Data from the Mental Health Advisory Team V report show that 11% of soldiers on their first deployment experienced mental health problems; that figure rose to 27% for those on their third tour.6

Third, it is estimated that up to 15% of all soldiers deployed to Iraq are women7; they have assumed an unprecedented combat support role in the war, resulting in greater risk for trauma. (See “Female Veteran Who Had Been Sexually Assaulted” case vignette.)Sadly, these women are also all too frequently victims of sexual harassment and assault. Although estimates from this conflict are not yet available, a study of female outpatients from Veterans Affairs hospitals found 23% had experienced sexual assault and 44% sexual harassment.8

Fourth, the enormous progress of battlefield medicine has created an unprecedented situation in which warriors who would have died in all previous wars from their injuries now survive. They must struggle with multiple devastating wounds—most commonly traumatic brain injuries (TBIs)9 often with co-occurring PTSD.10 Emergency physicians and mental health consultants who work in the ED often encounter returning veterans with subtle forms of cognitive impairment and medical conditions that have gone undiagnosed or untreated.

The goal of this review is to assist ED clinicians and psychiatrists who are faced with the challenges of caring for increasing numbers of returning veterans with combat-related physical and mental trauma. An overview of the epidemiology of mental health conditions identified in OIF/OEF veterans will serve as background for subsequent sections in which evidence-based assessment of PTSD, suicidality, and substance abuse in returning soldiers are the focus.11,12 Management approaches—including crises stabilization, initiation of psychotherapeutic and psychopharmacological treatments when clinically indicated, and (most important) education and counseling of patient and family regarding their mental health issues, safety, and arrangement of proper referral—will then be presented. Case vignettes will also be presented to illustrate these concepts.

It is hoped that the information, clinical guidance, and referral resources offered here will raise the comfort and competence level of ED clinicians so that they may see visits from our returning soldiers as a rewarding opportunity to serve those who have served.

EPIDEMIOLOGICAL BACKGROUND

One of the most comprehensive and authoritative sources for information about the mental health problems of returning soldiers is a 2007 longitudinal assessment of active duty and reserve soldiers returning from Iraq.13 In response to earlier methodological concerns about underestimation of the extent of mental health problems in OIF soldiers, the Department of Defense (DOD) conducted a Post-Deployment Health Re-Assessment (PDHRA) screening of 88,235 soldiers. Screening was administered immediately after return from deployment and then 3 to 6 months later. When compared with the prior study that utilized the Post-Deployment Health Assessment (PDHA), the population-based study that used the PDHRA documented significantly higher rates of mental health issues.14 Clinicians who administered the screening found that 20.3% of active duty and 42.4% of reserve soldiers required treatment for mental health issues. These findings highlight the need for effective outreach to reservists.